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MAR - MEDICATION ADMINISTRATION RECORD . MAK UNITS ONLY Created 10/04. HEADERS/SECTIONS: PAGE HEADER Type of MAR (i.e. Medication or IV) MAR Date Range Displays up to 5 Days of Med Summary ORDER SECTIONS ROUTINE ORDERS Scheduled Orders (i.e. QAM) PRN ORDERS STOPPED/DC’D
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MAR - MEDICATION ADMINISTRATION RECORD MAK UNITS ONLY Created 10/04
HEADERS/SECTIONS: PAGE HEADER Type of MAR (i.e. Medication or IV) MAR Date Range Displays up to 5 Days of Med Summary ORDER SECTIONS ROUTINE ORDERS Scheduled Orders (i.e. QAM) PRN ORDERS STOPPED/DC’D STOPPED/DC’D ROUTINE Expired/Discontinued Scheduled Orders STOPPED/DC’D PREOP/STAT/URGENT One Time Order STOPPED/DC’D PRN Expired/Discontinued PRN Orders MAR ORDER DETAILS: BRAND/GENERIC NAME IV DESCRIPTION DOSAGE STRENGTH ROUTE FREQUENCY (i.e. BID) ORDER START / STOP DATE ****FUTURE ORDER*** START DATE IN FUTURE AT PRINT TIME ****DISCONTINUED ORDER*** STOP DATE OCCURRED IN MAR DATE RANGE ****NO ADMINISTRATIONS*** PRN MEDS NOT CHARTED IN MAR DATE RANGE KEY COMPONENTS
LEGEND AND SYMBOLS • NOT ADMIN - * followed by Time, Initials • Example *2100BUSER • ADMIN – Time followed by Initials • Example 2100BUSER • NOT CHARTED - Time only • Example 2100 • HIST – Charted Occurrence has been revised • M= Charted Vitals or Pain Scale values • T = Temp • R = Respiration • HR = Heart Rate • PS = Pain Scale • BS = Blood Sugar • Blood Pressure noted by value/value
LEGEND AND SYMBOLS – cont’d • D= Free Text Charted Dose • Site – Site of Administration • T = Temp • R = Respiration • HR = Heart Rate • PS = Pain Scale • BS = Blood Sugar • Blood Pressure noted by value/value
CHARTING REASON AND EFFECT SECTION • Supplemental Section of MAR • Provides additional charting data • Reason • Documented reason med administered or not administered • Effect • Documented effectiveness for administered med
CHARTING HISTORY SECTION • Supplemental Section of MAR • Provides charted data revision information • Details old and new charted data information • Occurrence Status • Administered to Not Administered • Not Administered to Administered • Date and Time • Reason and Effectiveness • Administered Dose • Administration Site • Vital Sign, Pain Scale or Blood Sugar collected data • Revisions cannot be made to the original chart or cosign user identification
OTHER INFORMATION • PATIENT INFORMATION • Patient Identifiers • Allergies • NURSING ELECTRONIC SIGNATURES
MAR IMPORTANT FACTS • PATIENTS ON MAK UNITS • Permanent Chart Copy MAR for MAK Unit discharged patients will be printed directly to Medical Records at dayend • Unit MAR printed directly to unit each day • Normal print time - 10 PM • Used as a reference MAR
EXAMPLES MAR HEADERS, SECTIONS AND ORDER DETAILS
LAYOUT OVERVIEW MAR Date Range MED or IV MAR Header Charting Date Section Divider Order Details Section Header Based on Order Status
ORDER DETAILS OVERVIEW Brand/Generic Name Dosage, Strength, Route and Frequency Charting Information Start/Stop Date and Time Order Divider
ROUTINE ORDERS Chart Date Order Information Routine (Scheduled) Orders Charting Information
STOPPED/DISCONTINUED ORDERS Section Header Based on Order Status Stop Date/Time Stop date occurred in MAR date range
STOPPED DISCONTINUED ONE TIME ORDERS Stopped or Expired One Time Orders Start Stop Date are Equal
PRN ORDERS Order Section Header Active Order No Charted Occurrences
PRN STOPPED/DISCONTINUED Order Section Header Order Start/Stop Date Not Charted During MAR Date Range
FUTURE ORDER NOTATION Start Date in Future at Print Time
EXAMPLES LEGENDS AND SYMBOLS
CHARTING STATUS REVIEW Order Section Header ADMIN – Time and User ID NOT ADMIN – asterisk (*) f/b Time and User ID NOT CHARTED – Time w/o any other information HIST – Revision Details for Charted Occurrence
M = CHARTING DATA COLLECTION Vital Sign, Blood Sugar or Pain Scale Information
FREE TEXT DOSAGE AND SITE Free Text Dose Entered (D=) Administration Site Vital or Blood Sugar (BS) and or Pain Scale (PS)
EXAMPLES CHARTING REASON/EFFECT AND HISTORY
CHARTING REASON AND EFFECT Section Header Med, Occurrence Date/Time, Chart Time, User ID NOT ADMIN Reason PRN Reason
CHARTING HISTORY Order, Occurrence Date/Time, Charted Date/Time and Revised Data Element _ OLD Section Header Post – Revise, New Charted Date/Time and Revised Entry Value
MAR REVIEW IMAGE file contains MAR document images. Please review this file. THANK YOU!